SAMPLE Medical Release Authorization Form

Below is a SAMPLE Medical Release Authorization form for you to use as a guideline in constructing your form. NO TOURNAMENT TEAM should be without this form. Without a COMPLETED Medical Release form, NO PLAYER steps on a game field or practice field. NO EXCEPTIONS! If you are the manager of a Fastpitch Softball Travel team, YOU should have these forms on your person at all times. The thing about accidents is that you don't know when or where they will happen. So as the Softball Team Manager, you must be prepared at all times.

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AUTHORIZATION FOR MEDICAL TREATMENT

AUTHORIZATION FOR MEDICAL TREATMENT

TO WHOM IT MAY CONCERN:

I, _____________________________ (Parent/Legal Guardian) authorize the representative of the (YOUR LEAGUE OR TEAM NAME) bearing this document to act on my behalf in case my child _____________________________ requires emergency medical or surgical care, provided said representative makes a diligent effort to first contact me and obtain my preferences. If such efforts to contact me are unsuccessful, I authorize said representative to take such action on my behalf as his/her judgment dictates.

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Signature of Parent/Legal Guardian

Before me the undersigned authority on this day personally appeared ______________________________, known to be the person whose name is subscribed to the foregoing instrument, and acknowledges to me that he/she executed the same for the purposes and considerations therein expressed and in the capacity therein stated.

Given under my hand and seal of office this _____ day of _______________.

Notary Signature __________________________

Printed Name ____________________________

Notary Public in and for ____________________ County, State

Family Physician ______________________Phone_______________

Insuance Company ______________________Policy# ____________

Hospital Preference ________________________________________

Allergies and or special medical conditions _____________________

Parent/Guardian Contact Information:

Parent Guardian _________________Home Phone_______________

Mother’s Cell ________________Mother’s Work #_______________

Father’s Cell ________________ Father’s Work #________________

Local Emrgency Contacts:

Name* __________________________Phone ___________________

Name* __________________________Phone ___________________

*Please indicate relationship to player.

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